Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
EXECUTIVE SUMMARY
The Elderly Health Care Voucher Pilot Scheme (the Scheme) has been
in place for two years since its implementation in 2009. To assess the
effectiveness of the Scheme in enhancing primary care for the elderly, the
Government initiated an interim review in the second half of 2010. The
operation of the Scheme and utilization of the vouchers were examined. The
opinions and feedback of the elderly and healthcare service providers were
collected. This executive summary highlights the major findings of the review,
our evaluation of the extent to which the Scheme has achieved its objectives,
and our recommendations on the way forward when the current pilot period
ends on 31 December 2011.
Scheme Objectives
2.
The Chief Executive announced in the 2007‐08 Policy Address that
the Government would launch a three‐year pilot scheme in the 2008‐09
financial year under which elderly people aged 70 or above would be given
annually five health care vouchers worth $50 each to subsidise the primary
healthcare services they purchase from the private sector. The Scheme was
launched on 1 January 2009. It aims at providing partial subsidies for the
elderly to receive private primary healthcare services in the community, as
additional choices on top of the existing public primary healthcare services,
with a view to enhancing primary healthcare services for the elderly. The
Scheme implements the “money follows patient” concept on a trial basis,
enabling elderly people to choose within their neighbourhood private primary
healthcare services that best suit their needs.
3.
By providing partial subsidies for the elderly to choose private
primary healthcare in the community, it is expected that the Scheme could
help promote key ingredients of good primary care among the elderly and
healthcare service providers, including: continued relationship between the
elderly and their healthcare providers, more provision and utilization of
preventive healthcare services, and promotion of well‐being among the elderly.
With better access and a continuum of care from participating healthcare
service providers, we expect that more elderly people would be able to choose
private primary healthcare services close to their homes, and those elderly
people who need to rely on public healthcare services might also benefit from
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
the less burdened public primary care services.
Scope and Methodology of the Interim Review
4.
The interim review was conducted when the Scheme has been
implemented for its first half of the pilot period. Efforts have been made to
show the position up to 31 December 2010, save for situations where only
data up to 31 October 2010 were available for analysis purposes.
5.
The scope of the interim review covers the operation of the Scheme,
participation in the Scheme, utilization of vouchers, and feedback on the
Scheme in general and specific aspects. In particular, the interim review has
covered the following aspects by –
(a) examining voucher utilization by the elderly and participation of
healthcare service providers in the Scheme;
(b) collecting feedback from the elderly (both participating and
non‐participating) about the Scheme, including their awareness
of the Scheme, means to get to know the Scheme, reasons for
Scheme participation / non‐participation, desirable subsidy
amount, age eligibility, healthcare services coverage, service
delivery and perception about change in service fees and choice
of healthcare service after Scheme launch; and
(c) collecting feedback from healthcare service providers (both
enrolled and non‐enrolled) about the Scheme, including scheme
operation, service delivery, barriers of non‐participation and
reasons for withdrawal.
6.
Data collected for analysis and examination include statistical data
captured in the database of the eHealth System and purposely collected data
through structured questionnaires and focus group discussions. To this end,
studies were conducted by the School of Public Health and Primary Care of
Faculty of Medicine of the Chinese University of Hong Kong to collect feedback
from the elderly and healthcare service providers, viz. the opinion survey,
focus group discussions and the willingness‐to‐pay study.
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
Scheme Operation and Implementation
eHealth System
7.
The Scheme is administered through an electronic platform, viz. the
eHealth System. It is a web‐based system on which voucher‐based and
subsidy schemes operate. There is no need to issue or carry vouchers in
paper form as vouchers are issued and used through the electronic system.
The eHealth System performs the following functions ‐
(a) managing information on healthcare service providers and
enrolment;
(b) managing health care voucher accounts, including registering
eligible elderly people under the Scheme, issuing vouchers,
processing claims and recording usage;
(c) managing reimbursement of health care vouchers on a monthly
basis; and
(d) monitoring the Scheme by producing statistical reports to
facilitate planning and management of daily operation, and
generating alert messages whenever an irregularity in the use of
vouchers is detected to facilitate follow‐up actions and
investigations.
Use of Smart Identity Card Reader
8.
To further streamline procedures and provide greater convenience to
healthcare service providers, arrangements have been made in late 2010 to
make use of the “card face data” function in the chips of the Smart Hong Kong
Identity Card (HKID) for registration and authentication. It provides an
alternative means to participating healthcare service providers to register
persons eligible for vouchers and to access their accounts for claiming
vouchers, obviating manual input and ensuring data accuracy.
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
Privacy Impact Assessment and Privacy Compliance Assessment
9.
Measures to protect personal data privacy and to prevent abuse have
been instigated prior to and during Scheme implementation. A Privacy
Impact Assessment (PIA) and a Privacy Compliance Assessment (PCA) on the
design and operational procedures of the Scheme (phase I) were conducted
between July and December 2008 by Deloitte Touche Tohmatsu. This
ensures that the eHealth System has built‐in features to safeguard the security
of personal data transferred and stored within it in compliance with the
relevant legislation and government guidelines on protection of personal data
privacy. Prior to full launch of Smart HKID deployment for eHealth account
creation and voucher claims in October 2010, PIA and PCA on phase II of the
eHealth System were conducted between April and July 2010.
Security Risk Assessment and Audit
10.
In addition, the Department of Health (DH) engaged Computer and
Technological Solutions Limited (C&T) to conduct Security Risk Assessments of
phase I and II of the eHealth System in May 2008 and June 2010 respectively.
The current security risk level of eHealth System was found satisfactory, and
complied with the Government’s IT Security Policy and Security Regulations.
Post‐claim checking and Auditing
11.
As at 31 December 2010, a total of 852,721 claim transactions
involving 2,136,630 vouchers were processed for reimbursement and a total of
about $106 million have been reimbursed to enrolled healthcare service
providers. To ensure proper disbursement of funding for voucher claims, DH
has put in place a mechanism for checking and auditing voucher claims. It
involves (a) routine checking, (b) monitoring and investigation of aberrant
patterns of transactions, and (c) investigation of complaints. By end
December 2010, a total of 1,711 inspection visits were conducted, having
30,241 claims checked which represents 4% of claim transactions made. The
checking covers 77% of enrolled healthcare service providers with claims made.
The post‐claim checking and auditing revealed 25 cases of wrong claims,
representing 4% of the checked claims. These claims involved errors in
procedures or documentation. So far, two medical practitioners and one
Chinese medicine practitioner have been delisted from the Scheme.
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
12.
In mid 2008, the Corruption Prevention Department of the
Independent Commission Against Corruption offered corruption prevention
advice to DH on the administration of the Scheme prior to its launch. Also, to
ascertain whether there are potential risks to regularity, propriety or financial
control in the management of the Scheme and its operational mechanism, the
Audit Commission conducted a risk audit of the Scheme in 2009‐10. DH has
taken into account their suggestions and observations in fine‐tuning the
modus operandi of the Scheme.
Statistics on Scheme Participation and Utilization
Healthcare service providers: distribution of places of practice
13.
As at 31 December 2010, there are a total of 2,736 healthcare service
providers enrolled in the Scheme, involving 3,438 places of practice. Among
them, 39.6% (1,363) are in Kowloon, 23.4% (803) Hong Kong Island, 19.8%
(681) the New Territories West, 16.0% (549) the New Territories East and 1.2%
(42) Islands district. Of the 18 districts, Yau Tsim Mong district (549) has the
highest number of places of practice.
Healthcare service providers: Enrolment and participation rate
14.
Nine categories of healthcare professional who are registered in
Hong Kong are eligible to participate in the Scheme. They are medical
practitioners, Chinese medicine practitioners, dentists, chiropractors,
registered and enrolled nurses, physiotherapists, occupational therapists,
radiographers and medical laboratory technologists. Medical practitioners
account for the highest percentage of enrolled healthcare service providers
(52.3%) (1,431), followed by Chinese medicine practitioners (27.9%) (762) and
dentists (8.7%) (239).
15.
We estimate that the participation of medical practitioners, which
formed the majority of the enrolled healthcare services providers, is about
34.1% of the potential pool of medical practitioners actively providing
healthcare services in the private sector. The participation rate is on par with
other public‐private partnership schemes launched by the Government (e.g.
vaccination subsidy schemes). Participation among other eligible health
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
professions is relatively lower, at 16.1% for dentists and 12.5% for Chinese
medicine practitioners.
Elderly people joining the Scheme and claiming vouchers
16.
As at 31 December 2010, a total of 385,657 eHealth accounts
(representing 57% of eligible elderly people) were created and 300,292
eHealth accounts made voucher claims (representing 45% of eligible elderly
people). The number of eligible elderly people who have registered with the
Scheme has increased from 42% in end 2009 to 57% in end 2010. The
number of eligible elderly people who have registered with the Scheme and
made voucher claims has increased from 29% to 45% over the same period.
By the end of the second year of the pilot period, 131,801 elderly people, or
34% of elderly people who have registered with the Scheme (some 20% of the
eligible elderly people), used up the vouchers they were entitled to by then.
Claim transactions made: distribution among health professions, vouchers
claim pattern and usage
17.
With regard to the distribution of claim transactions among the
different professions, the majority (88.1%) (751,212 out of 852,721) of the
claim transactions are made by medical practitioners. Chinese medicine
practitioners (9.3%) (79,377) and dentists (1.9%) (16,396) rank second and
third in terms of utilization of vouchers. In terms of number of vouchers
claimed, medical practitioners constitute the largest proportion (87.1%)
(1,861,348 out of 2,136,630 vouchers), followed by Chinese medicine
practitioners (8.4%) (180,324) and dentists (3.5%) (74,751).
18.
Among the nine health professions, dentists have the highest average
number of voucher claimed per transaction (4.56 vouchers per transaction)
whereas the two lowest are medical practitioners (2.48 vouchers per
transaction) and Chinese medicine practitioners (2.27 vouchers per
transaction). The median of vouchers claimed per transaction for dentists is
4.75 whereas for medical practitioners and Chinese medicine practitioners are
2.77 and 2.43 respectively.
19.
For distribution of claims by reason of visit, a high proportion of claim
transactions (69.4%) are made for management of acute episodic conditions.
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
Follow‐up / monitoring of long term conditions account for 21.4%. Only 6.5%
and 2.7% of the claim transactions are made for preventive healthcare service
and rehabilitative care respectively.
20.
In terms of the number of vouchers used during each transaction, the
most common pattern (40.4%) is the use of two vouchers ($50 x 2), followed
by three vouchers ($50 x 3) (21.8%) and one voucher ($50 x 1) (21.1%). No
information on additional charges above the vouchers claimed is available as
healthcare providers are currently not required to supply such information.
21.
The eHealth statistics reveal that there are 25% eHealth accounts
with claim transactions involving two or more medical practitioners. 75% of
eHealth accounts with more than one claim transaction involved only one
medical practitioner. Most of the elderly tend to stay with the same medical
practitioner when using vouchers.
Opinion Survey and Willingness‐to‐pay Study
22.
To gauge the views and opinions of the elderly and healthcare service
providers about the Scheme, an opinion survey and four focus group
discussions were conducted between January and June 2010. In order to
further assess the willingness to pay for private primary healthcare services
among the elderly and to examine the level of subsidy that would incentivize
the elderly to change their healthcare seeking behaviour for private primary
healthcare services, a willingness‐to‐pay study was conducted in June and July
2010. These studies were undertaken by the School of Public Health and
Primary Care of Faculty of Medicine of the Chinese University of Hong Kong.
Opinion survey
23.
A total of 1,026 elderly people were recruited from public parks,
General Out‐patient Clinics of Hospital Authority, Elderly Health Centres of the
Department of Health and private general practitioners’ clinics. They
included participants and non‐participants of the Scheme. 70% of the elderly
said that they were aware of the Scheme. 35% said that they had actually
used the vouchers.
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
Reasons for using vouchers
24.
The survey reveals that elderly people who are used to seeing private
doctors are more ready and prepared than those relying on the public
healthcare system to register and make use of health care vouchers.
Comparison is made on use of vouchers for subpopulations according to the
type of doctors they usually visit. 24% of the elderly who usually visited
public doctors had made use of their vouchers. For those who usually visited
private general practitioners’ clinics, 49% of them had made use of their
vouchers during consultation. Comparison is also made for two sub‐groups,
viz. voucher users and non‐voucher users. For those who had made use of
vouchers, comparatively speaking, more elderly people were used to seeing
private doctors (27.5% usually visited private doctors, 49.4% visited both
private and public doctors, and only 23.0% usually visited public doctors).
For those who had never made use of vouchers, many of them were used to
seeing public doctors (43.2% usually visited public doctors, 40.2% visited both
private and public doctors, and only 16.6% usually visited private doctors).
The trigger for the use of vouchers was to make good use of the subsidy given
by the Government (36%), followed by shorter waiting time (33%), and
recommendation from friends, doctors and nurses (18%).
25.
For those who were aware of the Scheme but had never used their
vouchers (328), the reasons for not using vouchers included the healthcare
professionals whom they usually visited had not enrolled in the Scheme (24%),
the elderly were used to seeing public doctors (24%), the elderly were healthy
and did not have to consult healthcare professionals (23%), and they could not
find an enrolled healthcare professional nearby (22%).
Scheme awareness
26.
Some 71% of the interviewed elderly were aware of the Scheme.
Television advertisement (58%) was the key source of information, followed by
press and magazines (23%), and enrolled healthcare service providers (20%).
Among those elderly people who were aware of the Scheme, 47% of the
respondents felt the information provided to them was very, quite or fairly
sufficient. Among the 31% of elderly people who felt that the information
was insufficient, 53% would like to learn more on how to use the vouchers and
43% would like to know the channels where they could obtain the list of
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
enrolled healthcare professionals.
Scheme scope: subsidy amount
27.
Of the 1,026 elderly people who participated in the survey, 17% (35%
were voucher users) of them considered the annual subsidy amount of $250
was enough. 68% (39% were voucher users) of them considered the subsidy
amount of $250 per annum was not enough. Among those who considered
the amount was not enough, 36% preferred a subsidy amount of $300‐$500
and 32% preferred a subsidy amount of $501‐$1,000.
Scheme scope: age eligibility
28.
A total of 233 elderly people aged 60‐69 were interviewed during the
survey. The majority of the respondents (74%) thought that the age
eligibility should be lowered. Among them, 70% suggested lowering the age
to 65 years old.
Scheme scope: health service coverage
29.
Of the 1,020 elderly people who answered the question on coverage
of health services, 24% of elderly people thought that the coverage of health
services was insufficient. Among those who provided suggestions to
enhance the service coverage (173), 63% suggested adding public clinics and
28% suggested adding optometrist to the list of participating healthcare
professionals.
Scheme delivery
30.
Elderly people’s satisfaction of the Scheme was assessed by asking
whether they considered the Scheme useful or convenient to use. Some 65%
of interviewed elderly people (including both voucher users and non‐voucher
users) considered the Scheme useful. Among the 359 voucher users, 79%
considered the Scheme useful.
31.
In addition, the elderly were also asked on whether they considered
the vouchers were convenient to use. Some 64% of the interviewees
(including both voucher users and non‐voucher users) considered the
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
vouchers were convenient to use. Among the 359 voucher users, 80%
considered the vouchers convenient to use.
Scheme impact: choice of healthcare services after Scheme launch
32.
Of 1,026 elderly people who participated in the survey, one third
(32%) said that the Scheme encouraged them to use private primary care
service more than before. Some 66% of the elderly considered that the
Scheme did not change their behaviour in seeking private primary healthcare
services. Major reasons for no change of health seeking behaviour included
“used to seeing public doctors (26%)” and “the subsidy amount was too little
(24%)”.
Scheme impact: change in service fees after Scheme launch
33.
In the survey, the elderly were asked whether, from a perception
point of view, the consultation fees in general had increased subsequent to the
launch of the Scheme. 45% did not perceive any increase in consultation fees.
42% reported that they did not know whether the Scheme had led to any
increase in consultation fees. 14% perceived that the consultation fees
increased as a result of the Scheme.
Willingness‐to‐pay study
34.
To assess the elderly’s willingness‐to‐pay, their sensitivity towards
subsidy amount and health seeking behaviour, the Willingness‐to‐pay (WTP)
Study was conducted between June and July 2010 among 1,164 elderly people
aged 60 or above.
Willingness‐to‐pay and co‐pay
35.
The elderly were asked what was the maximum amount they were
willing to pay for a visit to see a private medical practitioner for different
conditions, and what was the maximum additional amount they were willing
to co‐pay if the Government provided subsidy for them to seek care in the
private sector. The results show that their willingness to pay (WTP) and the
amounts they were willing to co‐pay for private primary care services varied by
type of diseases and services.
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
36.
The average WTP amounts for general health conditions and acute
condition were within the current price range in private sector. However, the
WTP amounts for chronic condition and preventive care such as health check
and dental check fell below the price range in private sector. For chronic
conditions (47%) and dental check (54%), almost half of the respondents were
unwilling to pay for private healthcare service (WTP=$0). For health check,
36% of respondents were unwilling to pay for such service (WTP=$0). 32%
out of the total respondents were willing to pay an amount within or above
the price range for health check in private sector, and another 32% willing to
pay an amount below the market price range for health check. The elderly in
general were more willing to pay for acute episodic condition. 76% of elderly
were willing to pay for such services, including 65% willing to pay an amount
within or above the price range in private sector and 11% willing to pay an
amount below market price range. The main reasons for being unwilling to
pay for private healthcare service were “used to seeing public doctors” and
“private healthcare services were too expensive”.
37.
The elderly were also asked on the maximum amount they were
willing to pay for service managing minor illness and chronic illness, if the
Government provided them with different level of subsidy. It is noted that
more than half of the elderly were willing to co‐pay the same amount despite
different amounts of subsidies potentially provided by the Government.
Subsidy
38.
The elderly were asked the lowest amount of Government subsidy
that would encourage them (i) to see a private medical practitioner among
those who have been consulting public doctors for different diseases, (ii) to
have a health check regularly in the private sector among those who had not
done so, and (iii) to have dental check in the private sector. The findings
reveal that the subsidy requested varies by type of diseases and services. By
and large, the elderly requested more subsidy for chronic conditions, health
checks and dental check. In other words, the elderly were more willing to
pay for management of acute episodic diseases than chronic conditions and
preventive care.
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
Conclusion and Recommendations
39.
The interim review brings to light points worth noting regarding the
Scheme over the past two years through its initial operation, and at the same
time identifies areas requiring further attention. It deepens our
understanding of the behaviour of elderly people and healthcare service
providers in the use of health care vouchers and in seeking and providing
healthcare services. Its findings provide us with a foundation for making
observations and recommendations to improve the Scheme with a view to
achieving the objectives of enhancing the health of the elderly. It also
enables us to identify potential pitfalls in public‐private partnership that
provide useful inputs to the design of any other public‐private partnership
schemes for delivering healthcare.
40.
In overall terms, the review shows that the Scheme, while might not
have been able to readily achieve all the objectives it was intended for, has
made a start in establishing an effective and efficient mechanism for the
provision of healthcare services with government subsidies through
public‐private partnership. Meanwhile, the interim review also reminds us
that it is no easy task to induce behavioural changes among the elderly in
seeking and among the providers in providing healthcare services. It shows
that more efforts are required for the key notions of good primary healthcare
especially preventive care, as well as the concept of continuum of care to be
more widely promoted and accepted among elderly population and healthcare
providers. It also points to the need for the Scheme operation including its
supporting platform to be further strengthened.
Key Observations on the Scheme
(i) Scheme awareness and participation
41.
The findings of the interim review show that the Scheme has made a
good start in raising the awareness of the elderly to primary healthcare and
widening the choices of healthcare services to the elderly. The high
awareness of the elderly of the Scheme (over 70%) signifies that the Scheme
has gradually taken root in the community. This provides a good basis for
furthering the objectives of the pilot to enhance primary care for the elderly
and also for the promotion of other public‐private partnership schemes in
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
healthcare.
42.
The participation rate of the elderly (57% eligible elderly people
registered in the Scheme and 45% eligible elderly people have actually used
vouchers as at 31 December 2010) is noticeably higher than other
public‐private partnership schemes, signifying that the scheme has been able
to attract the attention of the elderly. However, given that one of the main
reasons for not using vouchers is that the elderly are used to seeking public
healthcare, and that these elderly are less likely to seek private healthcare,
more effort would be needed to encourage participation among the elderly.
43.
The participation rate of healthcare professionals (34% for medical
practitioners) has been on par with other public‐private partnership schemes
and geographically distributed across the territory, providing a large number of
choices for the elderly. However, given that one of the main reasons for not
using voucher is that the provider usually seen by the elderly has not enrolled
in the Scheme, there appears room for further improvement in promotion
efforts and participation rate among healthcare providers especially medical
practitioners.
(ii) Satisfaction with the Scheme
44.
Convenience and user‐friendliness are the two guiding principles in
designing and fine‐tuning the eHealth System on which the Scheme runs and
operates. In the survey about the general perception of the Scheme of both
the voucher users and non‐voucher users, a majority (64%) perceived that the
vouchers were convenient to use and 65% of interviewed elderly people
considered the Scheme useful. Among those who actually used the vouchers,
80% of them agreed that the vouchers were convenient to use and 79% of
them considered the Scheme useful. It shows that the Scheme has been
designed along the right track, and has provided a sound basis for the further
development of public‐private partnership in healthcare and subsidization
schemes aiming at enhancing primary healthcare.
45.
The operation of the Scheme had encountered various teething
problems at the initial phase of the Scheme, mostly concerning the use of the
electronic platform and the procedures for making claims. These have soon
been identified and addressed through the concerted efforts of parties
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
concerned, and the operation details of the Scheme have been streamlined
significantly since. Improvements on this front are recognized by elderly
users, as evidenced by the favourable response they gave in the opinion
survey concerning convenience of using vouchers. The use of vouchers in
electronic form through the eHealth System has helped promote
familiarization of e‐transaction among the elderly population and healthcare
providers. Some healthcare service providers, nevertheless, consider the
eHealth System can further be improved its user‐friendliness in the light of
clinical operation.
46.
After the initial phase, the operation of the Scheme including its
claims mechanism and eHealth System has been smooth and efficient, as
indicated by the low number of support requests or complaints from users,
the high compliance with pledged performance targets for claims processing,
and the effective monitoring of the operation of the Scheme and claims
pattern. The eHealth System established and refined enables us to
implement and further test the concept of “money follows patient”, and has
also benefited other public‐private partnership schemes (e.g. the vaccination
subsidy schemes) in providing a highly efficient platform for providing small
amount of government subsidies for healthcare services that are high in
volume.
47.
The Scheme had also established a network of healthcare providers
in the community who are mostly involved in the provision of primary
healthcare services to the elderly as well as the population at large. The
engagement of these providers through various public‐private partnership
schemes in delivery healthcare services, including the Elderly Health Care
Voucher Pilot Scheme, is instrumental to the implementation of our primary
care development strategy and development of primary health care services in
the community, as the private sector provides the majority of primary health
care services available to the population. In this regard, the Scheme has
taken a major step in the direction of establishing a public‐private partnership
model and platform that is necessary to enable change of healthcare seeking
and providing behaviour among users and providers.
(iii) Impact on healthcare seeking behaviour
48.
Broadly speaking, the Scheme has so far failed to induce any
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
noticeable behavioural change on the part of both users and providers of
primary healthcare services, during the first two years of the pilot period. In
particular, there is no evidence so far that the Scheme has brought about any
noticeable changes in the healthcare seeking behaviour among the elderly, or
resulted in an increase in the utilization and provision of preventive care
service. The review indicated that inertia of the elderly already seeking care
in the public sector, participation of healthcare providers that the elderly
usually see, and the relatively lower willingness‐to‐pay for preventive care are
main factors impeding the desired changes.
49.
The fact that only about 6.5% of health care vouchers claimed went
towards preventive service (with about 70% for episodic care) shows that most
elderly people give preventive services a low priority when it comes to
healthcare spending decision. The Willingness‐to‐pay Study also shows that
the elderly are less willing to pay for preventive care than episodic care. This
is a conception that has taken root among the elderly, and takes time and the
concerted efforts of all – Government, healthcare service providers, the media,
etc – to gradually induce a cultural change that puts more value and emphasis
on preventive care.
50.
It appears from the review that these behavioural changes are not
easy to induce, even with the aid of health care vouchers. The review
showed that elderly people who are used to seeing private doctors are more
ready and prepared than those relying on the public healthcare system to
register and make use of health care vouchers. On the other hand, those
elderly who are accustomed to seeking healthcare in the public system are
only marginally motivated to seek private primary care services on account of
the subsidies provided by the vouchers. Most elderly people tend to follow
their usual healthcare‐seeking pattern despite the availability of health care
vouchers.
51.
On the other hand, the review showed encouraging signs that the
elderly do tend to stay with the same healthcare provider they use vouchers
for especially in the case of medical practitioner. This is conducive to the
development of continuous doctor‐patient relationship and the concept of
family doctor providing comprehensive care to them. With the right design
and incentive, it is still possible for the Scheme to initiate the desired
behavioural changes essential to the development of comprehensive and
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
holistic primary healthcare. However, further and more in‐depth monitoring
and analysis would be needed to assess the effects of the Scheme on such
changes.
(iv) Price and subsidy for healthcare services
52.
The review indicates that subsidy, price and co‐payment required for
healthcare services are important factors to be considered in affecting the
elderly’s healthcare seeking behaviour. As the Willingness‐to‐pay Study
shows, the elderly in general are more willing to pay for curative care, with the
average falling within the price range for private curative healthcare. This
may also be one of the reasons for the voucher use concentrating on curative
care. On the other hand, the elderly are relatively much less willing to pay
for preventive and chronic disease care. This suggests that price and subsidy
level are key indicators to be monitored.
53.
The launch of the Scheme aims at providing partial subsidies for the
elderly to receive private primary care services in the community with a view
to enhancing primary healthcare services for the elderly and promoting
well‐being among them. The launch of the Scheme is also expected to
introduce the concept of co‐payment among the elderly in seeking healthcare
services. We note that in most instances when vouchers are used, the
elderly people concerned also meet part of their consultation fees out of their
own pocket. In this respect, the concept of co‐payment is realized.
However, as revealed by the Willingness‐to‐pay Study, there is only limited
incentive for the elderly to co‐pay more (in absolute terms) when the voucher
amount is increased. The relatively lower willingness to co‐pay for preventive
care than curative care and the concentration of voucher use on curative care
also makes it difficult to assess the effect of subsidy on co‐payment.
54.
Since the current Scheme does not require providers to provide more
specific information on healthcare services provided and additional
co‐payment charged over vouchers, we cannot ascertain with certainty if the
actual co‐payment charged for specific healthcare services are within
affordable range of the elderly, or if the co‐payment charged for specific
services are beyond the willingness‐to‐pay of the elderly. The sampling
survey suggests no significant degree of perceived increase in service fees,
though a small but not insignificant proportion of elderly people did report
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
perceived increase in service fees due to the use of vouchers. However, given
the sampling size and also lack of benchmark for comparison, we cannot
conclude with certainty how co‐payment level has played a role in influencing
the healthcare seeking behaviour of the elderly, and if increasing the subsidy
level might help change such behaviour.
55.
The above observations suggest that any increase in subsidy level
through higher voucher amount should be carefully calibrated to address the
intention to influence the desired healthcare behavioural changes and the
need to promote appropriate co‐payment for healthcare service utilization.
This is necessary to ensure that public monies are properly spent while
suitably addressing the objectives of the Scheme and the needs and concerns
of the elderly. The above also suggest that the monitoring and assessment of
price and subsidy level for different healthcare services should be
strengthened, so that the effect of government subsidy through the vouchers
on healthcare seeking and providing behaviour could be better evaluated.
(v) Coverage of healthcare service providers
56.
Optometrists are not currently included as eligible healthcare
providers under the Scheme. We note that some elderly people (28% of the
elderly as revealed in the opinion survey) have expressed the wish for
including Optometrists under the Scheme so that healthcare services provided
by them could also be met through health care vouchers. We also note in
particular that Optometrists with Part I registration under the Supplementary
Medical Professions Ordinance (Cap. 359) are qualified to provide certain
preventive care services concerning eye conditions, for example, to conduct
visual acuity examination for patients suffering from cataract and diabetes.
Their inclusion may thus help facilitate the greater use of preventive care by
the elderly.
Recommendations
57.
Having regard to the findings of the interim review, we recommend
that the Scheme be extended for another pilot period of three years, from
1 January 2012 to 31 December 2014, when the current pilot period ends on
31 December 2011. This is to allow further testing the effectiveness of the
Scheme in furthering the policy objectives to enhance the primary health care
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
for the elderly and to enable them to choose private primary health care in
their neighbourhood, through providing partial subsidies to the elderly
through health care vouchers.
58.
The proposed extension of the pilot period of the Scheme is in
keeping with the strategies for the promotion and development of primary
care as set out in the Strategy Document on Primary Care Development in
Hong Kong and can tie in with the Primary Care Campaign to be launched in
Q2 2011. In particular, the extended Scheme will allow a longer period to
assess the effectiveness of using vouchers to promote good primary care
among the elderly and healthcare providers, including: continued relationship
between the elderly and their healthcare providers, more provision and
utilization of preventive healthcare services, and the concept of continuum of
care and well‐being among the elderly and their healthcare providers.
59.
In this regard, on the basis of the findings of the interim review, we
recommend that the following specific measures be taken in conjunction with
the extension of the Scheme for the further three year pilot period ‐
(a) Increase the voucher amount per year for the next three‐year
pilot period (from 1 January 2012 to 31 December 2014) from
$250 to $500, while keeping the dollar value of each voucher the
same as before (i.e. $50 each). The number of vouchers given
to each eligible elderly person will be increased to ten. In this
connection, we note that there are demands for increasing the
voucher amount from the elderly and different quarters of the
community. We also note that an increased voucher amount
would help better assess the effectiveness of the Scheme in
achieving its policy objectives. On the other hand, we need to
carefully consider whether and, if so, to what extent an increase
in voucher amount would affect the healthcare seeking
behaviour among the elderly, the prices to be charged by
healthcare service providers, the amount elderly people are
willing to co‐pay and the emphasis elderly people put on
preventive services. We consider that the recommendation to
increase the voucher amount per year to $500 strikes a right
balance, and ensures that public monies are properly spent.
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
(b) There is a need to forge closer collaboration with healthcare
professionals to further promote the importance of primary care,
both among elderly people and service providers, and to
encourage utilization and provision of such services, having
regard to the reference framework to be developed for the
elderly under the primary care development strategy. Apart
from publicity and education, we will enhance efforts to
promote, in partnership with interested and qualified healthcare
service providers, a voluntary, protocol‐based elderly health
check programme at affordable prices for elderly people.
Elderly people aged 70 or above could meet the payment, partly
or wholly, through health care vouchers. The health check
programme will be modeled on the established practices and
service protocol of the Elderly Health Centres under the
Department of Health.
(c) Allow, on a one‐off basis on account of extension of the
three‐year further pilot period, the unspent balance of health
care vouchers under the current pilot period (ending
31 December 2011) to be carried forward into the next pilot
period (from 1 January 2012 to 31 December 2014). This is to
allow a fuller assessment of the effectiveness of the Scheme and
the utilization of health care vouchers in the next pilot period.
Given the significant financial liability arising from accumulation
of vouchers, all unused vouchers should lapse on the expiry of
the extended pilot period ending 31 December 2014,
irrespective of whether the voucher scheme will continue or
otherwise.
(d) Improve upon the operation of the Scheme and step up
monitoring over the use of health care vouchers by enhancing
the data‐capturing functions of the eHealth System in the
following two aspects –
(i)
Diagnosis information: we would explore the feasibility for
participating healthcare service providers to input more
specific information on the healthcare services provided to
voucher users.
For example, participating medical
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
practitioners would be required to provide more specific
clinical diagnosis, rather than the broad indication under the
current “reason of visit” arrangement, for their voucher
users so as to better enable the Administration to assess and
monitor the healthcare services provided to the elderly; and
(ii) Co‐payment: participating healthcare service providers
would be required to input the co‐payment made by an
elderly person for each consultation involving the use of
health care voucher(s). Coupled with (i), this will allow the
price and subsidy level for specific healthcare services to be
better monitored, and the impact of vouchers on healthcare
services be better assessed.
(e) Add optometrists with Part I registration under the
Supplementary Medical Professions Ordinance (Cap. 359) to the
Scheme with effect from the next pilot period, i.e.
1 January 2012, subject to the requirement that vouchers should
only be used for provision of healthcare services and must not be
used to cover the purchase of equipment (e.g. spectacles).
60.
Apart from the above, we do not recommend making any changes to
other rules of the Scheme. Specifically, we will, in the further three‐year
pilot period, continue to –
(a) Maintain the existing age eligibility, i.e. aged 70 or above. In
view that the effectiveness of the voucher model in changing
healthcare seeking behaviour has yet to be fully ascertained, we
consider it prudent to continue the pilot scheme with the
existing pool of eligible elderly and further assess the impact of
the Scheme on healthcare utilization and price. Given the
proposed increase in voucher amount, maintaining the pool of
eligible elderly would also help minimize the risk of price
inflation of private healthcare services due to increased
government subsidy.
(b) Keep the current rules on the use of health care vouchers (i.e.
usable for private healthcare services, but not for purchase of
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Elderly Health Care Voucher Pilot Scheme: An Interim Review – Executive Summary
drugs at pharmacies, purchase of medical items, or public
healthcare services, etc). Given the objective of the Scheme to
enhance primary healthcare for the elderly through
public‐private partnership and in view of concerns over
double‐subsidy using public money, we maintain the view that
vouchers should only be used for private services, but not for
medical items or public healthcare.
(c) Retain the current flexibility in using health care vouchers (i.e. no
limit on the number of vouchers that may be used for each
episode of healthcare services, no restriction on the type of
healthcare services or providers for which each voucher may be
used, and no limit on the amount of vouchers to be used for
different types of healthcare services or providers). This is to
allow the voucher model to be further and more fully assessed
on its effectiveness to enhance and incentivize various primary
healthcare services. However, restrictions or limitations may
need to be imposed eventually in the light of further review of
the Scheme especially voucher utilization over the extended
pilot period.
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